Physician - PACE

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 100,000 people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

ROLE OVERVIEW and PURPOSE

The PACE Physician provides comprehensive, person-centered medical care to older adults enrolled in the Program of All-Inclusive Care for the Elderly (PACE). The role centers on high-quality clinical care, including assessment, diagnosis, treatment, preventive care, chronic disease management, medication management, and coordination of care for participants with complex medical, functional, cognitive, and psychosocial needs.

As an active member of the interdisciplinary team (IDT), the PACE Physician contributes medical expertise to collaborative care planning and participant-centered decision making. The physician partners with nursing, rehabilitation services, behavioral health, social work, dietary services, home care, pharmacy, transportation, and other team members to support safety, function, independence, and quality of life.

The PACE Physician helps participants receive the right care in the right setting whenever possible. Care is primarily delivered through the PACE center and may also involve collaboration around care needs in the participant’s home, community, facility, hospital, or other care setting when clinically appropriate and aligned with the participant’s plan of care.

Schedule:

Monday-Friday 8am-5pm.

Responsibilities

• Provides comprehensive primary and geriatric medical care for PACE participants.
• Performs histories, physical examinations, medical assessments, and ongoing clinical evaluations.
• Diagnoses and manages acute and chronic medical conditions, including complex multimorbidity common in frail older adults.
• Develops individualized treatment plans that reflect the participant’s medical needs, goals, functional status, and overall plan of care.
• Prescribes medications, treatments, health regimens, and therapeutic interventions consistent with evidence-based practice and participant goals.
• Reviews medications and supports appropriate medication optimization, including deprescribing when clinically appropriate.
• Orders and interprets laboratory studies, imaging, diagnostic tests, and specialty recommendations.
• Provides preventive care and health maintenance when clinically appropriate and consistent with participant goals.
• Responds to urgent medical concerns and supports timely intervention to reduce avoidable escalation of care.

Geriatric and Complex Care Management

• Manages participants with frailty, cognitive impairment, functional decline, behavioral health needs, polypharmacy, advanced illness, and multiple chronic conditions.
• Considers functional status, mobility, fall risk, cognition, nutrition, caregiver support, and social drivers of health in clinical decision making.
• Assesses medical decision-making capacity when clinically indicated.
• Incorporates palliative care principles into…